Primary angiitis of the central nervous system in a patient with transient episodes of headache and aphasia: A case report

Primary angiitis of the central nervous system (PACNS) refers to a rare form of vasculitis of unknown cause, with a challenging diagnostic work-up. We report the case of a 57-year-old patient who presented with transient episodes of headache and global aphasia. Cerebrospinal fluid (CSF) examination revealed lymphocytic pleocytosis with moderate elevated protein and normal glucose. CSF and serum tests for infections and autoimmune/paraneoplastic antibodies were negative, except CSF polymerase chain reaction testing that detected Epstein-Barr virus (EBV). Magnetic resonance imaging of the brain with intravenous gadolinium showed meningeal enhancement and pachymeningitis. Due to continuous relapsing episodes of aphasia, a leptomeningeal and brain tissue biopsy was performed and revealed lesions of granulomatous necrotising vasculitis of medium-sized leptomeningeal and intracranial vessels, as well as negative in situ hybridism for EBV. A diagnosis of primary granulomatous necrotising angiitis of the central nervous system was made, and the patient was treated with intravenous methylprednisolone and oral cyclophosphamide, showing excellent response to treatment. Diversity in clinical and laboratory features makes it difficult for PACNS to be distinguished by other systemic vasculitides. Laboratory tests and neuroimaging can provide guidance in evaluation of the patients and exclude other possible causes, but tissue biopsy remains the gold standard for a definite diagnosis.

Quality metrics in the management of acute stroke in Greece during the first 5 years of Registry of Stroke Care Quality (RES-Q) implementation

Introduction

Establishment of a prospective stroke registry may promote the documentation and improvement of acute stroke care. We present the status of stroke management in Greece using the Registry of Stroke Care Quality (RES-Q) dataset.

Methods

Consecutive patients with acute stroke were prospectively registered in RES-Q registry by contributing sites in Greece during the years 2017-2021. Demographic and baseline characteristics, acute management, and clinical outcomes at discharge were recorded. Stroke quality metrics, with a specific interest in the association between acute reperfusion therapies and functional recovery in ischemic stroke patients are presented.

Results

A total of 3590 acute stroke patients were treated in 20 Greek sites (61% men, median age 64 years; median baseline NIHSS 4; 74% ischemic stroke). Acute reperfusion therapies were administered in almost 20% of acute ischemic stroke patients, with a door to needle and door to groin puncture times of 40 and 64 min, respectively. After adjustment for contributing sites, the rates of acute reperfusion therapies were higher during the time epoch 2020-2021 compared to 2017-2019 (adjusted OR 1.31; 95% CI 1.04-1.64; p < 0.022; Cochran-Mantel-Haenszel test). After propensity-score-matching, acute reperfusion therapies administration was independently associated with higher odds of reduced disability (one point reduction across all mRS scores) at hospital discharge (common OR 1.93; 95% CI 1.45-2.58; p < 0.001).

Conclusions

Implementation and maintenance of a nationwide stroke registry in Greece may guide the stroke management planning, so that prompt patient transportation, acute reperfusion therapies, and stroke unit hospitalization become more widely accessible, improving the functional outcomes of stroke patients.

Mass Sensing for the Advanced Fabrication of Nanomechanical Resonators

We report on a nanomechanical engineering method to monitor matter growth in real time via e-beam electromechanical coupling. This method relies on the exceptional mass sensing capabilities of nanomechanical resonators. Focused electron beam-induced deposition (FEBID) is employed to selectively grow platinum particles at the free end of singly clamped nanotube cantilevers. The electron beam has two functions: it allows both to grow material on the nanotube and to track in real time the deposited mass by probing the noise-driven mechanical resonance of the nanotube. On the one hand, this detection method is highly effective as it can resolve mass deposition with a resolution in the zeptogram range; on the other hand, this method is simple to use and readily available to a wide range of potential users because it can be operated in existing commercial FEBID systems without making any modification. The presented method allows one to engineer hybrid nanomechanical resonators with precisely tailored functionalities. It also appears as a new tool for studying the growth dynamics of ultrathin nanostructures, opening new opportunities for investigating so far out-of-reach physics of FEBID and related methods.

Seasonal adherence to, and effectiveness of, subcutaneous interferon β-1a administered by RebiSmart® in patients with relapsing multiple sclerosis: results of the 1-year, observational GEPAT-SMART study

BACKGROUND

Little is known about whether tolerability and adherence to treatment can be influenced by weather and temperature conditions. The objective of this study was to assess monthly and seasonal adherence to and safety of sc IFN-β1a (Rebif®, Merck) in relapsing-remitting multiple sclerosis (RRMS) patients using the RebiSmart® electronic autoinjector.

METHODS

A multicentre, prospective observational study in Greece in adult RRMS patients with EDSS < 6, under Rebif®/RebiSmart® treatment for ≤6 weeks before enrollment. The primary endpoint was monthly, seasonal and annual adherence over 12 months (defined in text). Secondary endpoints included number of relapses, disability, adverse events.

RESULTS

Sixty four patients enrolled and 47 completed all study visits (Per Protocol Set - PPS). Mean annual adherence was 97.93% ± 5.704 with no significant monthly or seasonal variations. Mean relapses in the pre- and post- treatment 12-months were 1.1 ± 0.47 and 0.2 ± 0.54 (p < 0.0001, PPS). 10 patients (22%) showed 3-month disability progression, 19 (40%) stabilization and 18 (38%) improvement. EDSS was not correlated to pre- (r = 0.024, p = 0.87) or post-treatment relapses (r = 0.022, p = 0.88).

CONCLUSION

High adherence with no significant seasonal or weather variation was observed over 12 months. While the efficacy on relapses was consistent with published studies, we could not identify a relationship between relapses and disability.

TRIAL REGISTRATION

Greek registry of non-interventional clinical trials ID: 200136 , date of registration: February 18th, 2013.

Intravenous thrombolysis for acute ischemic stroke in Greece: the Safe Implementation of Thrombolysis in Stroke registry 15-year experience

Background:

Intravenous thrombolysis (IVT) remains the only approved systemic reperfusion treatment for acute ischemic stroke (AIS), however there are scarce data regarding outcomes and complications of IVT in Greece. We evaluated safety and efficacy outcomes of IVT for AIS in Greece using the Safe Implementation of Thrombolysis in Stroke: International Stroke Thrombolysis Register (SITS-ISTR) dataset.

Methods:

All AIS patients treated with IVT in Greece between December 2002 and July 2017 and recorded in the SITS-ISTR were evaluated. Demographics, risk factors, baseline stroke severity [defined using National Institutes of Health Stroke Scale (NIHSS)], and onset-to-treatment time (OTT) were recorded. Safety outcomes included symptomatic intracranial hemorrhage (sICH) and 3-month mortality rates. The efficacy outcomes evaluated a reduction in baseline NIHSS score at 2 and 24 h following IVT onset, 3-month favorable functional outcome [FFO; modified Rankin scale (mRS) scores of 0–1] and 3-month functional independence (FI; mRS-scores of 0–2). The safety and efficacy outcomes were assessed comparatively with previously published data from SITS national and international registries.

Results:

A total of 523 AIS patients were treated with IVT in 12 Greek centers participating in the SITS-ISTR during the study period (mean age 62.4 ± 12.7; 34.6% women; median baseline NIHSS score: 11 points; median OTT: 150 min). The rates of sICH were 1.4%, 2.3%, and 3.8% according to the SIST-MOST, ECASS II, and NINDS criteria respectively. The median reduction in NIHSS score at 2 and 24 h was 3 [interquartile range (IQR): 1–5] and 5 (IQR: 2–8) points respectively. The 3-month FI, FFO and mortality were 66.5%, 55.6% and 7.9%. All safety and efficacy outcomes were comparable with available data from SITS-ISTR in other European countries.

Conclusions:

Our study underscores the safety and efficacy of IVT for AIS in Greece. Additional action is necessary in order to increase the availability of IVT in the Greek population and to include more centers in the SITS-ISTR.

Optomechanics with a hybrid carbon nanotube resonator

In just 20 years of history, the field of optomechanics has achieved impressive progress, stepping into the quantum regime just 5 years ago. Such remarkable advance relies on the technological revolution of nano-optomechanical systems, whose sensitivity towards thermal decoherence is strongly limited due to their ultra-low mass. Here we report a hybrid approach pushing nano-optomechanics to even lower scales. The concept relies on synthesising an efficient optical scatterer at the tip of singly clamped carbon nanotube resonators. We demonstrate high signal-to-noise motion readout and record force sensitivity, two orders of magnitude below the state of the art. Our work opens the perspective to extend quantum experiments and applications at room temperature.

Variables Affecting Factors Associated with Primary Headache

Primary headache syndromes’ development is associated with biological, psychological and social parameters. Factors such as daily habits, behavioral characteristics and sleep disorders also play an important role. We aim to identify the variables which affect the above factors. The study included 111 patients affected by primary headache. The patients were stratified into subgroups according to gender, age, occupation and headache type. Women attained higher scores than men in three of the evaluation rating scales and lower scores in the severity of dependence scale. Occupation was associated with SF36 and Hamilton anxiety scale. Unemployed had higher scores in Hamilton anxiety. Migraineurs and occupied individuals have lower SF36 scores. Women are associated with depression, anxiety and higher disability derived from headache. Men are more prone to dependence on opioids. Unemployment was linked with anxiety and well-being. The migraneurs presented a decreased level of quality of life.

Real-Time Measurement of Nanotube Resonator Fluctuations in an Electron Microscope

Mechanical resonators based on low-dimensional materials provide a unique platform for exploring a broad range of physical phenomena. The mechanical vibrational states are indeed extremely sensitive to charges, spins, photons, and adsorbed masses. However, the roadblock is often the readout of the resonator, because the detection of the vibrational states becomes increasingly difficult for smaller resonators. Here, we report an unprecedentedly sensitive method to detect nanotube resonators with effective masses in the 10^-20 kg range. We use the beam of an electron microscope to resolve the mechanical fluctuations of a nanotube in real-time for the first time. We obtain full access to the thermally driven Brownian motion of the resonator, both in space and time domains. Our results establish the viability of carbon nanotube resonator technology at room temperature and pave the way toward the observation of novel thermodynamics regimes and quantum effects in nanomechanics.

Cerebrospinal fluid analysis after unprovoked first seizure

The aim of this study was to determine cerebrospinal fluid (CSF) characteristics after an unprovoked first seizure (UFS). We reviewed the medical records of 71 patients with UFS who underwent lumbar puncture, and examined the CSF parameters. Each CSF parameter was evaluated separately for potential correlations with the other study variables. We observed an overall frequency of CSF abnormalities of 35.2%. CSF protein was the most common abnormal parameter (31%) and showed significant positive correlations with male gender (p=0.037) and older age (p=0.007). Only seven patients (9.9%) had an abnormal cell count (5-40 cells/μl). Higher CSF cell counts were found to predict a longer hospitalization period (p=0.005). No relationship with abnormal EEG findings could be established (p=0.169). This study is one of the few to evaluate postictal CSF parameters in a clinical setting, and to our knowledge the first to investigate these parameters specifically in the emergency department. The development of a rapid, easy-to-use test that does not require extensive laboratory equipment to differentiate UFS from other conditions could be of great value in everyday clinical practice.

Herpes Simplex Virus Type 2 Encephalitis as a Cause of Ischemic Stroke: Case Report and Systematic Review of the Literature

BACKGROUND AND AIM

Our objective is to describe a patient who developed an ischemic stroke as a complication of herpes simplex virus type 2 (HSV-2) encephalitis and to review the literature.

PATIENTS AND METHODS

A 45-year-old immune-competent Caucasian man presented with a 24-hour history of confusion and fever, and following clinical and laboratory examination was diagnosed with HSV-2 encephalitis. However, the brain magnetic resonance imaging also showed an acute ischemic infarct in the left frontal lobe corresponding to vascular territories of middle cerebral artery branches. Further screening failed to identify any other cause of the stroke. A systematic literature search was conducted in February 2015 using the PubMed database.

RESULTS

Six more cases of herpes simplex virus (HSV) central nervous system (CNS) infection that developed a definite ischemic stroke as a complication of the infection were identified.

CONCLUSIONS

Ischemic stroke, although infrequent, can complicate the evolution of herpes simplex meningitis or encephalitis. Clinicians should include HSV CNS infection as a possible cause of ischemic stroke, especially in young patients with ischemic stroke of unknown etiology.

Vertebrobasilar Dolichoectasia Induced Hydrocephalus: the Water-Hammer Effect

Vertebrobasilar dolichoectasia is a clinical entity associated rarely with obstructive hydrocephalus. We present a 48-year old male with a profound dilatation of the ventricular system due to a dolichoectatic basilar artery, as appeared in imaging studies. The patient suffered from longstanding hydrocephalus and presenile dementia. The underlying mechanism for obstructive hydrocephalus due to vertebrobasilar dolichoectasia is considered to be both a water-hammer effect and a direct compression of adjacent structures. We suggest prompt surgical intervention upon diagnosis as a first choice treatment in order to avoid further complications.

Atomic monolayer deposition on the surface of nanotube mechanical resonators

We study monolayers of noble gas atoms (Xe, Kr, Ar, and Ne) deposited on individual ultraclean suspended nanotubes. For this, we record the resonance frequency of the mechanical motion of the nanotube, since it provides a direct measure of the coverage. The latter is the number of adsorbed atoms divided by the number of the carbon atoms of the suspended nanotube. Monolayers form when the temperature is lowered in a constant pressure of noble gas atoms. The coverage of Xe monolayers remains constant at 1/6 over a large temperature range. This finding reveals that Xe monolayers are solid phases with a triangular atomic arrangement, and are commensurate with the underlying carbon nanotube. By comparing our measurements to theoretical calculations, we identify the phases of Ar and Ne monolayers as fluids, and we tentatively describe Kr monolayers as solid phases. These results underscore that mechanical resonators made from single nanotubes are excellent probes for surface science.

Predicting 30-day case fatality of primary inoperable intracerebral hemorrhage based on findings at the emergency department

BACKGROUND

Early survival of patients with intracerebral hemorrhage (ICH) depends on several factors, including the location and size of the hematoma and the level of consciousness on admission. The aim of our study was to estimate the case fatality of primary inoperable ICH 30 days after the event in our hospital and to identify clinical and laboratory characteristics, recordable at the Emergency Department (ED), which could predict death at 30 days.

METHODS

Clinical and laboratory data on all patients with primary ICH admitted to our hospital were retrospectively collected.

RESULTS

Between January 2011 and June 2013 191 patients with primary ICH were admitted to our hospital. The 30-day case fatality rate was estimated to be 31.9%, as 61 patients died within 30 days after the ICH. Five variables were independently associated with 30-day case fatality: each decreased point at the Glasgow Coma Scale (GCS) is associated with a 1.3-fold increase in the odds of death at 30 days; infratentorial location and intraventricular extension are associated with a 5.5-fold and a 4.7-fold increase in the odds of death at 30 days, respectively; each centimeter of the maximum diameter of the hematoma and each point increase of the international normalized ratio (INR) are associated with a 1.9-fold and a 3.5-fold increase in the odds of death at 30 days, respectively.

CONCLUSIONS

GCS score on admission, infratentorial location of the hematoma, intraventricular extension of the hematoma, INR on admission, and maximum diameter of the hematoma are the 5 variables that are independently associated with 30-day case fatality of primary inoperable ICH. EDICH is introduced as a new grading scale, which includes laboratory and clinical findings at the ED and has predicting value of the 30-day case fatality.

Determinants of depression among patients with epilepsy in Athens, Greece

OBJECTIVE

Depression is common among patients with epilepsy. The aim of our study was twofold: to estimate the prevalence of a major depressive episode and to identify its determinants among patients with epilepsy treated in the largest Greek hospital in Athens.

METHODS

All consecutive patients with epilepsy that visited the epilepsy outpatient clinic of Evangelismos General Hospital were invited to participate in the study. Ninety-four patients met our inclusion criteria.

RESULTS

A diagnosis of a current major depressive episode was established in 21 out of 94 eligible to participate (22.3%) patients. Being a female was associated with a 19.68-fold increase in the odds of having a major depressive episode (95% CI 3.39-114.14, p=0.001); being unemployed was associated with a 6.46-fold increase in the odds of having a major depressive episode (95% CI 1.23-34.07, p=0.028), and each extra seizure experienced per month was associated with a 1.38-fold increase in the odds of having a major depressive episode (95% CI 1.03-1.85, p=0.031).

CONCLUSION

Unemployment, female gender, and seizure control are important determinants of a major depression episode among patients with epilepsy.

Validation of the Greek version of the Neurological Disorders Depression Inventory for Epilepsy (NDDI-E)

The Neurological Disorders Depression Inventory for Epilepsy (NDDI-E) was developed as a screening tool for symptoms of major depressive episodes in people with epilepsy. Our study describes the development, validation, and psychometric properties of the Greek version of the NDDI-E. A consecutive sample of 101 patients with epilepsy, eligible to participate in the study, has been assessed using the Mini International Neuropsychiatric Interview version 5.0.0 and the NDDI-E. All patients had no major difficulties in understanding or answering the questions of the Greek version. Cronbach's alpha coefficient was 0.74. Receiver operating characteristic analysis showed an area under the curve of 91% (95% CI=83%-99%; SE: 0.040, p<0.001). At a cutoff score of greater than 15, the NDDI-E showed a sensitivity of 91%, a specificity of 81%, and a negative predictive value of 97%.

Natalizumab-related progressive multifocal leukoencephalopathy in Greece

BACKGROUND & OBJECTIVES

Progressive multifocal leukoencephalopathy (PML) may complicate natalizumab treatment in multiple sclerosis patients. We sought to characterize the clinical and laboratory features of natalizumab-related PML (NR-PML) cases from Greece.

METHODS

Pharmaceutical industry, national drug authorities and all neurology departments within the Greek territory were asked to provide data for cases of NR-PML until October 2012. Collected cases were classified according to their level of diagnostic certainty using the five-level system introduced by Mentzer et al. (2012).

RESULTS

Thirteen NR-PML cases were identified by the neurology departments. Data were provided for only 9 cases. PML manifestations appeared after a median number of 40 (21-52) natalizumab infusions. All but two patients were treated with plasma exchange and some were treated adjunctively with mirtazapine while the others were treated with mefloquine. IRIS developed in 6 cases after a median time of 6 (2-10) weeks from PML presentation and were treated with different regimens of corticosteroids. PML was fatal in 3 cases. The median EDSS after a median follow-up time of 12 (8-23) months in the surviving cases was 4.75 (2-8.5).

CONCLUSIONS

Outcomes for collected NR-PML cases varied from death to returning to baseline. Close surveillance is essential for early diagnosis and treatment of NR-PML patients.

Non-coronary myocardial infarction in myasthenia gravis: Case report and review of the literature

Cardiovascular adverse events in patients with myasthenia gravis (MG) are rare, but the early recognition of such events is crucial. We describe a case of a non-coronary myocardial infarction (MI) during the initial treatment period with pyridostigmine bromide in a female patient with MG. Clinicians should be cautious about the appearance of potential MI in patients with MG. A baseline electrocardiogram is advocated, when the early recognition of the MI clinical signs and the laboratory findings (myocardial markers) are vital to the immediate and appropriate management of this medical emergency, as well as to prevent future cardiovascular events. In this case report possible causes of myocardial adverse events in the context of MG, which may occur during the ongoing treatment and the clinical course of the disease, are discussed.

Extensive bilateral intracranial calcifications: a case of iatrogenic hypoparathyroidism

This is a case of a 69-year-old male patient with long-standing iatrogenic hypoparathyroidism after total thyroidectomy. The clinical evaluation revealed mild neurological symptoms and excessive brain calcinosis. Intracranial calcification that affects structures other than the basal ganglia and the cerebellum is a rare manifestation of postoperative hypoparathyroidism. Detection of brain calcinosis in patients who had total thyroidectomy can motivate clinicians in further investigation of possible hypoparathyroidism with measurement of calcium and phosphorus serum levels.

Thymoma and myasthenia gravis: clinical aspects and prognosis

Myasthenia gravis is present in a significant proportion of patients with thymoma. We investigated particular features of the clinical behavior of thymoma and its relationship to myasthenia in a retrospective study of 79 patients who underwent thymectomy for thymoma during the last 20 years. The presence of myasthenia gravis, Masaoka stage, World Health Organization histotype, myasthenia response, and survival were analyzed. The mean age of the patients was 56.1 ± 12.4 years, and 39 had myasthenia gravis. A significantly higher proportion of patients with myasthenia was found in B2 and B3 histotypes compared to A, AB, and B1. Among myasthenic patients, 33.3% had no response, 50% had a partial response, and 16.7% achieved complete remission. During the follow-up period, 16 (21.1%) patients died. Mean survival was 4.8 ± 1.4 years for patients with no myasthenia response, whereas those with a partial or complete myasthenia response had significantly better survival.

Backaction amplification and quantum limits in optomechanical measurements

Optical interferometry is by far the most sensitive displacement measurement technique available, with sensitivities at the 10(-20) m/square root(Hz) level in the large-scale gravitational-wave interferometers currently in operation. Second-generation interferometers will experience a tenfold improvement in sensitivity and be mainly limited by quantum noise, close to the standard quantum limit (SQL), once considered as the ultimate displacement sensitivity achievable by interferometry. In this Letter, we experimentally demonstrate one of the techniques envisioned to go beyond the SQL: amplification of a signal by radiation-pressure backaction in a detuned cavity.

Scheme to probe optomechanical correlations between two optical beams down to the quantum level

The quantum effects of radiation pressure are expected to limit the sensitivity of second-generation gravitational-wave interferometers. Though ubiquitous, such effects are so weak that they have not been experimentally demonstrated yet. Using a high-finesse optical cavity and a classical intensity noise, we have demonstrated radiation-pressure induced correlations between two optical beams sent into the same moving mirror cavity. Our scheme can be used to retrieve weak correlations at the quantum level and has applications both in high-sensitivity measurements and in quantum optics.

Success, safety, and efficacy of implantation of diamond-like carbon-coated stents

The aim of this study was to evaluate safety and clinically defined efficacy of the implantation of a new stent coated with diamond-like carbon (DLC stent), in a group of patients who underwent percutaneous transluminal coronary revascularization procedures in two hemodynamic centers. This study was an observational prospective nonrandomized study that included 196 patients with a total of 236 significant de novo atheromatous coronary lesions, in which 245 DLC stents were implanted. The primary end point of this study was a composite of major cardiovascular events (death or acute myocardial infarction with or without Q) and need for target lesion revascularization (TLR) or target vessel revascularization (TVR) procedure during the first 48 hours and at 6 months after the DLC stent implantation. All patients had a myocardial perfusion imaging study with Tl(201) at 6 months after DLC stent implantation. Only patients with a myocardial perfusion imaging study indicative of myocardial ischemia were then submitted for a new coronary angiogram. No major cardiovascular event or emergency TVR occurred during hospitalization. At 6-month follow-up no major cardiovascular event occurred either, whereas the rate for TLR was 5.6% and that for TVR was 7.65%. This preliminary study provides enough clinical evidence that implantation of intracoronary bare metal stents coated with diamond-like carbon is associated with high success rates, safety, and efficacy, both in the hospital and at the 6-month follow-up after the interventional procedure.

Open ended circulation pattern: A rare case of a protective coronary artery variation and review of the literature

Persistent intercoronary communications, forming the so-called open ended coronary circulation pattern, are rare findings of coronary angiography. A case of intercoronary connection between the left anterior descending artery (LAD) and the right coronary artery (RCA), with an obstructive lesion, and no evidence of myocardial infarction is presented. This is an exceptional variant, only 20 cases of which were found in the literature. The potential protective role of this anomaly against occlusive coronary artery disease is discussed and similar reports are reviewed.

Reply to “The role of soluble interleukin-6 receptor in inflammatory diseases” [Immunol Lett 2005;98(1):171]

We agree with the comments of Mr. Maggio and colleagues. The exact role of serum IL-6R and the relation between this and the IL-6/sIL-6R complex in inflammatory disorders has not been completely clarified. We suggest a discrepancy between sIL-6R concentrations and measurable IL-6/sIL-6R complex, not excluding the positive contribution of sIL-6R as a marker of neuro-immunoregulatory and inflammatory status in the central nervous system.

Unexpected opening of a totally occluded septal branch originating from an atheromatous lesion successfully treated with angioplasty and stenting

In about 50% of patients who undergo a percutaneous coronary intervention for an atheromatous lesion there is a side branch that is involved in or borders on the lesion. In such cases, the invasive cardiologist must make every attempt to rescue this branch. We present an unusual case of unexpected opening of a side branch of a coronary artery after balloon angioplasty and stenting of the main vessel. In a patient with subtotal occlusion of the anterior descending coronary artery, angioplasty and stenting caused the opening of a previously totally occluded septal branch that originated from within the treated atheromatous lesion. This case is an unusual example of atheromatous plaque shift that had an unexpectedly beneficial result.

Comparison of the extent and severity of coronary artery disease in patients with acute myocardial infarction with and without microalbuminuria

The extent and severity of coronary atherosclerosis were compared between 43 microalbuminuric and 87 normoalbuminuric nondiabetic patients with acute myocardial infarction. Patients with microalbuminuria had significantly greater scores of the severity (Gensini score) and extent (Hamsten score) of coronary artery disease (p <0.001).

Soluble interleukin-6 receptor (sIL-6R) in cerebrospinal fluid of patients with inflammatory and non inflammatory neurological diseases

IL-6 acts on target cells via the ligand-binding protein interleukin-6 receptor (IL-6R) and the affinity-converting and signal-transducing glycoprotein 130 (gp130). Soluble interleukin-6 receptor (sIL-6R) has an agonistic role because the soluble complex (IL-6/sIL-6R) can activate cells that do not express IL-6R and an antagonistic role as it enhances the inhibitory activity of sgp130. Soluble forms of both receptors, sIL-6R and sgp130, regulate the action of IL-6. sIL-6R was measured by a sensitive enzyme-linked immunosorbent assay in paired sera and cerebrospinal fluid (CSF) from 46 patients with inflammatory neurological diseases (IND), 45 patients with relapsing-remitting multiple sclerosis (RR-MS), 13 patients with primary progressive multiple sclerosis (PP-MS), 17 patients with other non inflammatory neurological diseases (NIND) and 13 mentally healthy individuals--healthy controls (HC). Patients with RR-MS had CSF sIL-6R levels comparable to those from patients with IND, but higher than patients with NIND and HC. A positive correlation between the CSF/serum albumin (QAlb) and CSF sIL-6R levels was observed in IND but not in RR-MS patients indicating that CSF sIL-6R levels in IND patients could be influenced by serum sIL-6R and blood brain barrier (BBB) permeability properties. RR-MS patients had higher values of [CSF/serum sIL-6R:CSF/serum albumin] (sIL-6R index) than IND patients suggesting that in multiple sclerosis (MS), the increase in CSF sIL-6R could be due to intrathecal synthesis of sIL-6R. The finding of increased CSF sIL-6R concentrations (>979 pg/ml) with sIL-6R index (>4.66), in correlation with positive oligoclonal bands in RR-MS patients, suggests that values of sIL-6R index > 4.66 indicate intrathecal increase of sIL-6R and might be used as an indicator of neuroimmunoregulatory and inflammatory processes in the central nervous system (CNS).

Accident vasculaire ischémique cérébral et méningo-encéphalite à herpès simplex 1

The etiology of stroke in young patients is often unknown. Although systemic infections as well as specific infection agents, like herpes zoster virus or cysticercus, are often considered as risk factors, there are no indications that herpes simplex type 1 plays a role in the pathogenesis of stroke. We present the case of a young patient who suffered a stroke during a meningoencephalitis due to herpes simplex 1 and we review the relevant literature for a possible relation between the two entities.

Aneurysm of the mitral-aortic intervalvular fibrosa as a rare cause of angina pectoris: angiographic demonstration

Aneurysms of the mitral-aortic interventricular fibrosa (MAIF) are exceptionally rare complications, commonly following aortic valve endocarditis. This report describes the angiographic findings of such an aneurysm, in a patient who developed an uncommon symptomatology of unstable angina pectoris, caused by the aneurysm's expansion against the coronary arteries. Surgical treatment is also discussed.

Communication between a nongrafted left internal mammary artery and left anterior descending coronary artery following saphenous vein bypass grafting

A case is described in which a pericardial branch of a nongrafted left internal mammary artery communicated directly with the distal left anterior descending artery, following saphenous vein bypass grafting. This type of collateralization following coronary artery bypass surgery seems to be very rare, and perhaps could protect the myocardium from severe ischemia.

Stress echocardiography using adenosine combined with nitroglycerin-dobutamine in the detection of viable myocardium in patients with previous myocardial infarction

The aim of this study was to assess the value of adenosine (A) and the combination of nitroglycerin (N) with dobutamine (D) stress echocardiography (SE) in the identification of viable myocardium. The clinical and electrocardiographic (ECG) effects of both tests were also evaluated. Fifty-two coronary artery disease patients, aged 56.4 +/- 8 years, with left ventricular dysfunction due to a previous myocardial infarction (mean ejection fraction: 49 +/- 8%) were included in the study. Cardiac catheterization was performed in all patients before A (140 micrograms/kg/minute for five minutes) and the combination of N with D (5-10 micrograms/kg/minute) stress echocardiography. On the echocardiogram, the left ventricle was divided into 16 segments and wall motion was graded semiquantitatively from 1 (normal) to 4 (dyskinesia). The echocardiographic index was also estimated. A segment was considered viable during A infusion when resting asynergy showed deterioration of one grade or more. In contrast, segmental viability was considered to be present during the combination of N with D infusion when resting asynergy showed improvement of one grade or more. A thallium 201 single photon emission computed tomography (SPECT) with reinjection was performed as reference standard for the identification of viable myocardium. Stress echocardiography during infusion of A was associated with short-duration angina attacks in 3 (5.8%) patients and transient complete atrioventricular (AV) block in 1 (1.9%), whereas during the combination of N with D infusion, 6 (11.5%) patients experienced ventricular bigeminy lasting for a short period. ST segment elevation greater than 1 mm was recorded in those leads having a Q wave, in 19 (36.5%) patients. In 10 of these 19 (52.6%), viable myocardium was present in SPECT, as it was in 33 patients (63.5%) having no ST segment elevation (P = NS). Of a total of 832 segments that were graded during A-SE, 276 exhibited resting asynergy and the remaining 556 had normal motion and thickening at rest. The echocardiographic index during A infusion increased from 1.52 +/- 0.22 to 1.71 +/- 0.24 (P < 0.001), whereas during D and N infusion it decreased from 1.53 +/- 0.31 to 1.30 +/- 0.42 (P < 0.001). With SPECT considered as the gold standard for the identification of viable myocardium, sensitivity, specificity, and positive and negative predictive values of A-SE in detecting viable myocardium were 54%, 86%, 65% and 80%, respectively. The respective values for the combination of nitroglycerin with D-SE were 91%, 89%, 78%, and 96%, respectively. Stress echocardiography during A, and the combination of N with D, constitute safe methods in the identification of viable myocardium. The detection of ST segment elevation in the ECG leads with a Q wave during the combined infusion of nitroglycerin and dobutamine is not related to the presence of viable myocardial tissue. The A-SE provide moderate diagnostic accuracy, while the combination of N with D during SE is much superior in detecting viable myocardium.

Angioplasty of a left anterior descending artery originating from the right sinus of Valsalva (discussion in decision making)

In this case report, we describe a successful percutaneous transluminal coronary angioplasty of an abnormally originating left anterior descending artery from the right sinus of Valsalva. We discuss about the decision making in this rare and challenging case, since there is more than one opinion as to which is the appropriate treatment in this group of patients.

Ventricular extrasystolic arrhythmias in exercise testing. II. Haemodynamic correlations

Exercise testing (ET) has been used for assessing the arrhythmogenic tendency of myocardium in patients (pts) with coronary heart disease. It has been suggested that coronary patients with left ventricular (LV) dyssynergy are prone to present ventricular extrasystolic arrhythmia (VA) during ET. We studied the functional status of the LV in a group of 25 coronary patients who presented VA during ET (Group A), and compared the results with a group of 87 patients without VA during ET (Group B). No statistically significant difference was found between the two groups in end-diastolic pressure, ejection fraction, and extent of dyssynergy of the LV. Furthermore, no significant difference was noted in the extent of development of the collateral circulation.

Anomalous origin of the right coronary artery arising from the circumflex artery

A case of anomalous origin of the right coronary artery discovered among 3100 selective coronary arteriograms is described. This artery was arising from the circumflex artery. The position, distribution, and configuration of this coronary artery was as a normal right coronary artery, except that its origin was in the peripheral segment of the circumflex artery. This anomalous origin is very rare and seems not to give rise to any clinical significance.